Paige Abrams, Summer Clay, Shauna Fassino, Megan Hofer, Marika Schipper, Carly Smith

Multiple Sclerosis

What is MS?- Affects nerve cells in brain and

spinal cord- Worsening function of

voluntary muscles- Eventually progressing to

quadriplegia- No cure

What Is Like To Have MS?

Pathophysiology

Multiple sclerosis (MS) involves an immune-mediated process in which an abnormal response of the body’s immune system is directed against the central nervous system (CNS). The exact antigen — or target that the immune cells are sensitized to attack remains unknown, which is why MS is considered by many experts to be "immune-mediated" rather than "autoimmune"

● Within the CNS, the immune system attacks myelin as well as the nerve fibers themselves.

● CNS myelin is produced by special cells called oligodendrocytes. PNS myelin is produced by Schwann cells. Both perform the same function — to promote efficient transmission of a nerve impulse along the axon.

● The damaged myelin forms scar tissue (sclerosis)

Pathophysiology ContinuedWhen any part of the myelin sheath or nerve fiber is

damaged or destroyed, nerve impulses traveling to and from the brain and spinal cord are distorted or interrupted.

T cells, a type of white blood cell, somehow become sensitized to proteins in the CNS. When T cells become activated, they enter the CNS through blood vessels and produce damaging inflammation. Once in the CNS, these T cells not only injure myelin, but also secrete chemicals that damage nerve fibers (axons).

The disease is thought to be triggered in a genetically susceptible individual by a combination of one or more environmental factors.

Types of MS

Clinical Manifestations

Clinical Manifestations

“Everyday is a struggle due to the fatigue… Sometimes I just have to stay in bed because I can’t function.” -Tracy

Subjective & objective data: fatigue, pain or paresthesias, changes in vision, tinnitus or vertigo, Uhthoff’s sign, dysphagia, slurred speech (dysarthria), muscle spasticity and uncontrollable movements, muscle weakness, bowel and bladder dysfunction, nystagmus, and cognitive changes. (ATI)

Findings may be vague, so diagnosis may not be made for several years. (ATI)

Relapses and remissions (ATI)

DiagnosisRequires one of the following:

1.Two or more exacerbations 1 month apart that last at least 24 hours

OR2.History of repeated exacerbations and remissions (with or without

complete recovery) followed by more severe and progressive manifestations lasting 6 months or more

OR

3.Slowly increasing manifestations for at least 6 months(LeMone, 2013)

Diagnostic Tests❖MRI: Most definitive test

➢ Presentation of lesions

❖Cerebrospinal Fluid (CSF) Analysis:

➢ Shows increased number of T-lymphocytes reactive to antigens= presence of immune response

➢ Elevated levels of Immunoglobulin G (IgG) in CSF

❖CT Scan: Brain

➢ Shows atrophy and white matter lesions

Risk FactorsOnset of MS is typically between

20 and 40 years of age

Occurs twice as often in women

Etiology unknown

Family history (1st degree relative) of MS in many cases

Association is shown with the interleukin-7 and interleukin-2 receptor genes

Smoking

Medications Three main typesImmunosuppressive agentsCorticosteroids Antispasmodics

Medications (cont.) Immunosuppressive agents: used to reduce frequency of relapse

Azathioprine (Imuran) and Cyclosporine (Sandimmune)

Monitor for long term effects, be alert for manifestations of infection, assess for HTN, assess kidney function Corticosteroids: used to reduce inflammation in acute

exacerbations

Prednisone Monitor for increased risk for infection, hypervolemia, hypernatremia, hypokalemia,

hyperglycemia, GI bleeding and personality changes

Medications (cont.)Antispasmodics: used to treat muscle spasticity

Dantrolene (Dantrium), Tizanidine (Zanaflex), Baclofen (Lioresal) and Diazepam (Valium)

Observe for increased weakness, monitor for liver damage (tizanidine and dantrolene)

Report jaundice and increased weakness to provider and avoid stopping baclofen suddenly

Other medications Interferon beta (betaseron): immunomodulator, used to prevent or

treat relapse

Carbamazepine (Tegretol): anticonvulsant, used for paresthesia

Docusate Sodium (Colace): stool softener, used for constipation

Propantheline: anticholinergic, used for bladder dysfunction

Primidone (Mysoline) and Clonazepam (Klonopin): beta-blockers, used for tremors

Patient TeachingTeach about proper fluid hydration (at least

2,000mL a day) & bladder elimination

Teach signs and symptoms of UTI’s

Inform patient and family about local community resources and respite care

Teach pulmonary hygiene- TCDB&IS

Teach pt to perform self care activities during peak energy and encourage frequent rest periods

Teach about side effects of drugs

Avoid CNS depressants when taking medications, can increase sedation

Avoid factors that trigger relapse:

Virus and infectious agents

Living in a cold or hot climate, or high humidity environment

Physical injury

Stress

Pregnancy

Fatigue

Physical overexertion

Temperature extremes

Hot shower/bath

Community ResourcesFamily Caregiver Alliance:785 Market Street, Suite 750, SF(415) 434-3388www.caregiver.org

Redwood Caregiver Resource Center:1140 Sonoma Ave., Suite 1B, Santa Rosa(707) 542-0282www.redwoodcrc.org

Caregiver Support Self Help Group:October 10th, 12:00pmRound Table Pizza, 2065 Occidental Rd., Santa

Rosa

National MS Society Research Video

Current Research: Myelin Repair● Early human trials are underway to investigate therapies aimed

at repairing the myelin sheeth.

● Myelin Repair is seen as a promising approach for restoring lost function and slowing down, or even stopping the progression of the disease·

● Therapies focus on protecting the nervous system from MS

damage and/or stimulate myelin repair. They can inject a variety of molecules including: ○ Bionure’s BN201 & GLI1○ Clinical trials involving an IV infusion referred to as anti-

LINGO or Biogen were linked to 70% of participants remaining free of disease activity and showed no signs of progression.

Current Research: Stem Cell Therapy● Stem cell therapy is any treatment that

uses or targets stem cells, which are the types of cells that differentiate into many different specialized cells in our bodies.

● The National MS Society is currently supporting 12 research projects exploring various types of stem cells.

● With Hematopoietic Stem Cell Therapy (HSCT) they attempt to “reboot” the immune system, which is responsible for damaging the brain and spinal cord in MS.

Many types of stem cells are being explored for their potential benefits for treating MS.

● HSCs (haematopoietic stem cells) ● MSCs (mesenchymal stem cells)● NSCs (neural stem cells) ● hESCs (human embryonic stem cells) ● iPSCs (induced pluripotent stem cells)

Current Research: Exercise & DietExercise

Research has shown exercise is helpful in managing many MS symptoms. Studies show that patients who participated in an aerobic exercise program benefited from:

better cardiovascular fitnessimproved strengthbetter bladder and bowel functionless fatigue and depressiona more positive attitude/mood

improvementincreased participation in social

activitiesYoga

Diet● Recently there have been links

to MS management with patients everyday diet. A diet high in Vitamin D and Biotin is recommended.

● Researchers have also found links between our gut microbiome and MS. We know that these bacteria can affect the immune system and that the gut microbiome can affect the type of MS patients have. As of this year research has now initiated a trial of probiotics in MS patients.

Nursing Considerations:● Monitoring of: visual acuity, speech patterns (fatigue with talking), swallowing,

activity tolerance, and skin integrity.● Aid to decrease the risk of developing a urinary tract infection by encouraging fluid

intake. Assist the client with bladder elimination.● Monitor cognitive changes and plan interventions. (Reorient the client. Place objects used

daily in routine places.)● Use a communication board to help with dysarthria.● Discuss coping mechanisms and sources of support.● Apply eye patches to treat diplopia and alternate between eyes every few hours. ● Instruct client to visually scan environment.● Exercise and stretch involved muscles.●Cluster care to aid in energy conservation and plan rest periods.● Promote and maintain safe home and hospital environment to reduce the risk of injury.

References ATI RN Adult Medical Surgical Nursing Review Module (9th ed). (2013). Assessment Technologies Institute.ATI RN Pharmacology for Nursing Review Module (6th ed). (2013). Assessment Technologies Institute.Diet & Nutrition. National Multiple Sclerosis Society. Retrieved from http://www.nationalmssociety.org/Living-Well-With-MS/Health-Wellness/Diet-NutritionLeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-Surgical Nursing: Critical Thinking in Patient Care (5th ed). Upper Saddle River, NJ Pearson.Multiple Sclerosis and Acupuncture. (2016). Acupuncture Technology News. Retrieved from

http://www.miridiatech.com/news/2011/03/multiple-sclerosis-and-acupuncture/ Now MS Research. YouTube. Retrieved from https://www.youtube.com/embed/UXfxhlFik4o Restoring What's Been Lost. (2016). National Multiple Sclerosis Society. Retrieved from

http://www.nationalmssociety.org/Research/Research-We-Fund/Restoring-What-s-Been-Lost Stem Cells in MS. National Multiple Sclerosis Society. Retrieved from

http://www.nationalmssociety.org/Research/Research-News-Progress/Stem-Cells-in-MS Weiner, Howard L. MD. Multiple Sclerosis Research. The McCourt Foundation.

(http://mccourtfoundation.org/research/ms-researchWhat Is MS? National Multiple Sclerosis Society. Retrieved from http://www.nationalmssociety.org/What-is-MSWhat is it like to have MS? (2016). YouTube. Retrieved from https://www.youtube.com/watch?v=HwWI25XtV7Y